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ANALYTICAL REPORT
Year : 2012  |  Volume : 8  |  Issue : 1  |  Page : 138-141

Long-term survival in a patient with metastatic oropharynx squamous cell carcinoma to liver


1 Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse, NY 13210, USA
2 Department of Otolaryngology, SUNY Upstate Medical University, Syracuse, NY 13210, USA
3 Department of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA
4 Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, USA

Date of Web Publication19-Apr-2012

Correspondence Address:
Varun Kumar Chowdhry
750 East Adams Street, Syracuse, NY 13210
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.95196

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 > Abstract 

The traditionally held view is that the patients with metastatic disease cannot be cured and should be treated palliatively as it was believed that the patients will eventually succumb to the disease progression due to lack of effective treatments for systemic disease. In this article, we report our experience in a patient who was diagnosed with metastatic oropharynx squamous cell carcinoma to the liver, who has now survived five years since the original diagnosis, and is three years disease free. This case report illustrates the curative potential in selected patients with limited burden of metastatic disease with aggressive local therapy to all known sites of disease. It underscores the importance of imaging modalities in monitoring progression of disease, and most importantly illustrates the importance of multidisciplinary care for oncology patients.

Keywords: Head and neck cancer, oligometastatic disease, radiation therapy


How to cite this article:
Chowdhry VK, Hsu J, Lemke S, Kittur D, Hahn SS. Long-term survival in a patient with metastatic oropharynx squamous cell carcinoma to liver. J Can Res Ther 2012;8:138-41

How to cite this URL:
Chowdhry VK, Hsu J, Lemke S, Kittur D, Hahn SS. Long-term survival in a patient with metastatic oropharynx squamous cell carcinoma to liver. J Can Res Ther [serial online] 2012 [cited 2020 Jul 3];8:138-41. Available from: http://www.cancerjournal.net/text.asp?2012/8/1/138/95196


 > Introduction Top


The concept of oligiometastatic disease presents a paradigm shift in our understanding of metastatic processes. It was traditionally believed that patients with any systemic metastasis would not benefit from aggressive local therapy due to a high occult systemic disease burden. However, more recently, the evidence is surfacing that oligometastatic disease treated aggressively to all involved sites may lead to prolonged survival. [1] We report a patient treated at our institution who had histologically confirmed metastatic oropharynx squamous cell carcinoma to the liver who was treated definitively to both sites, head and neck and liver, now living seven years from his original diagnosis, and is three years disease free from his hepatic resection.


 > Case Report Top


The patient is a 55-year-old gentleman who presented to his primary care doctor after having a sore throat. He was initially treated conservatively with medications for possible reflux or infection for six months, but his symptoms did not improve. He also noted a 60 pound weight loss during this same time period. The patient was referred to an otolaryngologist who subsequently noted a 2 cm diameter left level II cervical lymph node. A flexible laryngoscopy performed at that time revealed a 4-cm diameter ulcerative mass at the left base of the tongue that extended inferiorly to the lingual surface of the epiglottis and crossing the midline. A tracheostomy was performed out of concern of impending airway obstruction and a biopsy performed from left base of tongue revealed poorly differentiated invasive squamous cell carcinoma. A PET/CT scan showed abnormally increased metabolic activity in the site of the left base of tongue, left level II cervical lymph node (SUV 12.7) and focal areas of increased uptake in the right lobe of liver (SUV 5.2) suspicious for liver metastasis [Figure 1]a, b, and [Figure 2]. A core biopsy from the lesion in the liver performed confirmed the diagnosis of metastatic squamous cell carcinoma with basaloid features.
Figure 1: PET- CT scan at original diagnosis indicating large laryngeal mass (a) and liver metastasis (b) at time of diagnosis

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Figure 2: CT scan of the abdomen and pelvis revealing a 2.0 cm diameter low density lesion in the anterior segment of the right hepatic lobe at the time of presentation

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Treatment course and follow up

As the patient was found to have a large primary tumor with single lymph node involvement and the only site of distant metastatic disease confined to the liver, the decision was made to treat his disease in the head and neck aggressively but without radical surgery to preserve function of the tongue. Depending on the response of the locoregional disease to combined chemotherapy and radiotherapy, and the response of liver metastasis to chemotherapy, the definitive treatment for the liver was deferred. The patient was treated by concurrent chemo radiotherapy using carboplatin (AUC times 4) and taxotere (75 mg per meter squared) every three weeks as radio sensitizers and amifostine as radio protector for salivary glands. He received 5040 cGy in 28 fractionations to the bilateral neck with a boost to the primary disease site, 2000 cGy in 10 fractionations making total dose to base of tongue to be 7040 cGy.

Following the completion of radiation therapy the loco regional disease achieved a complete response so that he was treated by adjuvant chemotherapy with carboplatin and taxotere for two cycles. He developed allergic reaction to taxotere and so his chemotherapy was changed to Xeloda 1500 mg twice daily with two weeks on and one week off cycle for nine months, which resulted in hand and foot syndrome. Unfortunately, the patient had radiographic evidence of progression of liver metastasis by CT scan and PET scan performed following the completion of the combined chemoradiotherapy [Figure 3]. Because the patient's liver metastasis was the only site of disease, the determination was made to aggressively treat the liver metastasis. As a result, he received CyberKnife radiosurgery to the site of liver metastasis. Approximately one year later, the patient was noted to have an increase in size of the liver lesion of CT scan [Figure 4]. A PET scan performed on also confirmed an increase in the size of the liver lesion [Figure 5]. Given the fact that there were no other signs of metastatic disease by PET/CT scan, the determination was made for the patient to seek a surgical consultation for definitive resection. The patient underwent definitive surgical resection of the right hepatic lobe. [Figure 6] shows a post-operative CT-scan. The pathology from the liver resection revealed metastatic squamous cell carcinoma with basaloid features consistent with the oropharynx primary. He had an uneventful post-operative course and he did well since the surgery without evidence of disease recurrence. He is currently working fulltime and has no limitation in physical activity. The last follow-up examination including flexible laryngoscopy performed as well as PET-CT imaging has shown no evidence of recurrence [[Figure 7]a, b and [Figure 8]a, b] at two and three years since hepatic resection respectively. The final pathology specimen from the liver resection revaled with metastatic sqamous cell carcinoma to the liver [Figure 9]. The patient is working full time.
Figure 3: CT scan of the abdomen and pelvis following the completion of defi nitive therapy to the head and neck cancer as well as adjuvant Xeloda suggesting progression

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Figure 4: Possible progression suggested on previously treated lesion with Cyber Knife radiosurgery

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Figure 5: PET/CT scan performed following CyberKnife radiosurgery suggesting residual disease

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Figure 6: CT scan obtained following hepatic resection

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Figure 7: PET scan fi ve years after the original diagnosis, over one year after hepatic resection with no evidence of metastatic disease

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Figure 8: PET-CT scan seven years following initial diagnosis, and three years following liver resection showing no evidence of disease

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Figure 9: Gross and histological sections from patient's liver resection consistent with squamous cell carcinoma

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 > Discussion Top


In this article, we report a long-term survivor from metastatic oropharynx squamous cell carcinoma, with no evidence of disease over five years after the diagnosis of metastatic disease, with a three year disease free interval to date. While ultimately the biology of the patient's disease has a major impact on any given patient's prognosis, the management of this patient underscores the importance of multidisciplinary care as physicians from medical oncology, radiation oncology, otolaryngology, and surgery were all involved in the management and follow-up of this patient.

The initial attempt to manage this patient involved definitive treatment to the primary site, followed by systemic chemotherapy. The initial local therapy for the patient's metastatic disease in the liver was stereotactic body radiation therapy. The ability to provide a high dose of radiation in a small number of fractions is more commonly used in the oligometastatic setting. Randomized trials evaluating the role of radiosurgery for intracranial disease have demonstrated both a local control and a survival benefit. [2],[3] In Japan, a retrospective series of 41 patients with 5 different sites of disease has shown the ability to provide local tumor control, and possibly overall survival. [4]

Close follow-up of this patient through both CT and PET suggested a recurrence of disease. As there was no evidence of additional metastatic disease, the patient had surgical consultation and definitive surgical treatment performed. Patchell has shown a functional as well as a survival benefit to surgical resection of metastatic disease to the spinal cord and brain. [5],[6] Surgical resection of hepatic metastasis has been shown to provide palliation, as well as the possibility of cure in patients with colorectal cancer. [7],[8] This report suggests that such a benefit to hepatic resection may be possible in patients with head and neck primary cancer.

 
 > References Top

1.Hellman S, Weichselbaum RR. Oligometastases. J Clin Oncol 1995;13:8-10.  Back to cited text no. 1
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2.Andrews DW, Scott CB, Sperduto PW, Flanders AE, Gaspar LE, Schell MC, et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: Phase III results of the RTOG 9508 randomised trial. Lancet 2004;363:1665-72.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Kondziolka D, Patel A, Lunsford LD, Kassam A, Flickinger JC. Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases. Int J Radiat Oncol Biol Phys 1999;45:427-34.  Back to cited text no. 3
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4.Inoue T, Katoh N, Aoyama H, Onimaru R, Taguchi H, Onodera S, et al. Clinical outcomes of stereotactic brain and/or body radiotherapy for patients with oligometastatic lesions. Jpn J Clin Oncol 2010;40:788-94.  Back to cited text no. 4
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5.Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: A randomised trial. Lancet 2005;366:643-8.  Back to cited text no. 5
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6.Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990;322:494-500.  Back to cited text no. 6
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7.Scheele J, Stangl R, Altendorf-Hofmann A. Hepatic metastases from colorectal carcinoma: Impact of surgical resection on the natural history. Br J Surg 1990;77:1241-6.  Back to cited text no. 7
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8.Heslin MJ, Medina-Franco H, Parker M, Vickers SM, Aldrete J, Urist MM. Colorectal hepatic metastases: Resection, local ablation, and hepatic artery infusion pump are associated with prolonged survival. Arch Surg 2001;136:318-23.  Back to cited text no. 8
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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