Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor

Transcription

1 Squamous Cell Carcinoma with Isolated Upper Mediastinum Nodal Metastasis with Unknown Primary: the Role and Treatment Consideration of RT with Chemotherapy Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of squamous cell carcinoma with isolated upper mediastinum nodal metastasis with unknown primary; to discuss the role and treatment consideration of RT with chemotherapy Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 56 year-old female patient, 胡 OO, was referred to us for radiotherapy assessment of upper mediastinum mass with unknown primary for preparing CCRT. S: 1. Hoarseness for 2 months 2. Right upper mediastinum LNs post biopsy showed squamous cell carcinoma. 3. In 2008/09, she was referred to us for further CCRT assessment. Hx: Alcohol, Betel nut, Cigarettes 0.5 PPD for years Review of symptoms: mild dysphagia for weeks O: 1. ECOG: 1, ambulatory status, speech: mild to moderate hoarseness 2. PE: no LNs; no knocking pain; no limb edema 3. ***Pathology in 2008/08, right upper mediastinum LN, biopsy: metastatic squamous cell carcinoma, Gr. II. 4. Neck CT in 2008/07: a 3 cm LN over the right upper mediastinum, para-trachea region; left vocal cord thickness, suspicious mass lesions; multiple small LNs over bilateral level I and II. 5. CXR in 2008/08: neg. 6. No abdominal sono and bone scan data.

2 Key Image(s): Fig. 1. Fig. 2. Fig. 3.

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) Q7: In your opinion, what sites could be the primary tumor site in this case?

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: no specific clinical cancer stage can be defined in this case due to unknown primary site now. Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no pathology cancer stage can be defined in this case. Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Metastatic squamous cell carcinoma, moderately differentiated, of the right upper mediastinum, para-tracheal region, with unknown primary, suspect left vocal cord lesion Q5: What is your Oncology Plan for this case? A5: 1. further studies (upper aero-tract/gi-tract endoscopy, ABD sono, and bone scan) 2. arrange 3DCT for preparing CCRT; OPD FU 2 weeks later Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: metastatic carcinoma over the upper mediastinum with unknown primary; unresectable disease (2). Goal: potentially curative in definitive CCRT setting (3). Target & Volume: upper mediastinum with bilateral neck (from level II to SCF) with in-field esophagus, trachea, larynx, and pharynx region (4). Technique: CT-based IMRT (5). Dose & Fractionation: 7200 cgy in 40 fractions to the gross tumor; 6300 cgy in 35 fractions to the highest-risk nodal basin; and, 5040 cgy in 28 fractions to the low-risk elective nodal basin. Q7: In your opinion, what sites could be the primary tumor site in this case? A7: In this case of squamous cell carcinoma with isolated upper mediastinum nodal metastasis with unknown primary, the most possible primary sites could be as follows: esophagus, lung, trachea, thymic carcinoma, sub-glottis larynx, thyroid, hypopharynx. The other relatively low possible primary sites could be as follows: other head-and-neck region and other distant sites (i.e., intra-abdomen and intra-pelvis). Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/03/29

5 Key Image(s): (with marked) Fig. 1. Fig. 1. The metastatic nodal lesion over the right upper mediastinum, right para-trachea region (as the long white arrow); wall thickness over the right lateral wall of the upper esophagus, suspect the esophagus in primary (as the short white arrow). Fig. 2. Fig. 2. At the upper level, the esophagus wall thickness also noted (as the white arrow). Fig. 3. Fig. 3. The Tl-201 cancer survey shows increase uptake over the right lateral wall of the esophagus, further suspect the primary site in the esophagus (as the white arrow and red crossers).