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Case presentation

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History

23 yr old lady presented with complaints of

Nasal obstruction since 4months

Decreased vision since last 15 days

Right sided neck pain for last 15 days

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MRI findings

Large lobulated T1 hypointense and T2 homogeneously hyperintense

nasopharynx, nasal cavity and extending inferiorly into the oropharynx

measuring ~6.8x3.5cm

The lesion occludes the nasal cavity,causes significant compromise of

the nasopharyngeal lumen and partially occludes the oropharyngeal l

umen

Extent:

Superiorly, it extends upto the roof of the ethmoid air cells ,

floor of the anterior cranial fossa with small extradural component in

denting the basifrontal lobes

Inferiorly, it extends into the oropharynx predominantly along theright lateral wall with involvement of the tonsillar fossa and indenting

the tongue; the lower extent of the lesion is at C3 vertebral level.

The uvula is also involved.

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Anteriorly extends into the nasal cavity with involvement nasalturbinates

Extension of soft tissue along the walls of the right maxillary sinus is noted. Occlusion of bilateral infundibula with fluid see

n in the bilateral maxillary sinuses. The frontal and sphenoethmoid recesses are also occluded resulting in fluid signal withinthe sinuses; soft tissue thickening along the walls of the sphenoid sinus is also noted

Posteriorly, the lesion extends into the prevertebral space with

involvement of the prevertebral muscles at C1-3level, more significant on the right side

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Laterally, the lesion extends into the para pharyngeal space bilaterally

right more than left. On the right side, it encases the carotid vessels

and indents the deep lobe of the parotid gland. The right masticat

or space is involved with involvement of the medial and lateral ptery

goids. Extension of soft tissue into the right retromolar trigone regi

on is also noted. On the left side, the lesion indents the deep lobe

of the parotid ; the carotid vessels lie posterior to the lesion.

On the right side, intraorbital extension in the extraconal compartm

ent causing displacement of the lateral and inferior recti

Posteriorly, extension of soft tissue along the superior orbital fissure

and into the cavernous sinusNodes: Enlarged level 2a and level 1b nodes measuring upto 10 mm

on the right side

The visualised brain parenchyma is normal.

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Chemotherapy

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Radiation therapy

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Extended radiation treatment fields

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IFRT for NHL

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IFRT for NHL

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INRT

Radiother Oncol.2013 Oct;109(1):133-9. doi: 10.1016/j.radonc.2013.07.013. Epub

2013 Sep 7.

Reduction of the treated volume to involved node radiation therapy as part of

combined modality treatment for early stage aggressive non-Hodgkin's

lymphoma.

Verhappen MH1, Poortmans PM, Raaijmakers E, Raemaekers JM BACKGROUND AND PURPOSE:

This retrospective study investigated whether focused involved node radiation

therapy (INRT) can safely replace involved field RT (IFRT) in patients with early

stage aggressive NHL.

PATIENTS AND METHODS: We included 258 patients with stage I/II aggressive NHL who received combined

modality treatment (87%) or primary RT alone (13%). RT consisted of a total dose

of 30-40 Gy in 15-20 fractions IFRT or INRT. We compared survival, relapse pattern,

radiation-related toxicity and quality of life for both RT techniques.

http://www.ncbi.nlm.nih.gov/pubmed/24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Verhappen%20MH[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Poortmans%20PM[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Raaijmakers%20E[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Raemaekers%20JM[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Raemaekers%20JM[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Raemaekers%20JM[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Raemaekers%20JM[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Raaijmakers%20E[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Raaijmakers%20E[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Raaijmakers%20E[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Poortmans%20PM[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Poortmans%20PM[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Poortmans%20PM[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Verhappen%20MH[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Verhappen%20MH[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed?term=Verhappen%20MH[Author]&cauthor=true&cauthor_uid=24021344http://www.ncbi.nlm.nih.gov/pubmed/24021344http://www.ncbi.nlm.nih.gov/pubmed/24021344http://www.ncbi.nlm.nih.gov/pubmed/24021344http://www.ncbi.nlm.nih.gov/pubmed/24021344

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RESULTS:

Type of RT was not related to the outcome in either the uni- ormultivariate survival analysis. Relapses developed in 59 of 252 patients(23%) of which 47 (80%) were documented as distant recurrence only.Failure of the INRT technique was noted in one patient. There was nosignificant difference in acute radiation-related toxicity between RT-groups

but IFRT showed a significantly higher incidence of higher grade toxicities.Patients treated with INRT had a significantly better physical functioningand global quality of life compared to the IFRT group.

CONCLUSIONS:

Given the retrospective nature of this study, no solid conclusions can be

drawn. However, in view of the equivalent efficacy and more favorabletoxicity profile, the replacement of IFRT by INRT in combination withchemo-(immuno)-therapy looks very attractive for patients with earlystage aggressive NHL.

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Follow up

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Response

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